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Original Article
Grafting of autologous concentrated bone marrow processed using a
point-of-care device for patients with osteonecrosis of the femoral
head: A phase 1 feasibility and safety study
Yasuhiro Homma
a
,
b
,
*
, Yosuke Masubuchi
b
, Yuichi Shirogane
a
, Hirofumi Amano
c
,
Yuko Muramoto
c
, Masashi Nagao
a
,
b
, Ryuji Okuno
a
, Tomonori Baba
a
, Ken Yamaji
c
,
Naoto Tamura
c
, Kazuo Kaneko
a
, Muneaki Ishijima
a
a
Department of Orthopaedics, Faculty of Medicine, Juntendo University, Tokyo, Japan
b
Medical Technology Innovation Center, Juntendo University, Japan
c
Department of Internal Medicine and Rheumatology, Faculty of Medicine, Juntendo University, Tokyo, Japan
article info
Article history:
Received 28 November 2021
Received in revised form
1 February 2022
Accepted 2 March 2022
Keywords:
Osteonecrosis of the femoral head
Bone marrow
Point-of-care device
abstract
Introduction: Along with the accumulating reports of autologous concentrated bone marrow (CBM)
grafting for osteonecrosis of the femoral head (ONFH), the related medical device, a “point-of-care de-
vice”has also been recently developed. However, no study has confirmed the feasibility, safety, and
efficiency of CBM grafting using a specific point-of-care device.
Materials and methods: We designed this phase I, prospective clinical study to evaluate the feasibility and
safety of autologous CBM grafting processed using a point-of-care device, the BioCUE system, in patients
with ONFH. The primary outcomes were the safety and adverse event (AE), the secondary outcomes
included pain score; hip function score; ONFH stage using X-ray; and the volume of the osteonecrotic
area on 3T MRI. Besides, safety quality tests on the final product of concentrated bone marrow were
performed.
Results: Two patients (a 34-year-old man and a 33-year-old woman; three hips) with systemic lupus
erythematosus were included. The incidence of AEs was 100% such as pain or transient fever after the
operation, but all AEs were nonserious. No peri-operative complications were observed. Pain and hip
function score remained unchanged from the preoperative to the postoperative observational periods.
Safety quality test demonstrated were all negative or under the threshold.
Conclusion: The feasibility and safety of grafting of concentrated autologous CBM in patients with ONFH
using a point-of-care device were confirmed. A further clinical study aiming for the authorization of this
procedure should be conducted in the future.
©2022, The Japanese Society for Regenerative Medicine. Production and hosting by Elsevier B.V. This is
an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/
4.0/).
1. Introduction
Osteonecrosis of the femoral head (ONFH) severely decreases
the activity of daily living (ADL) in young patients because of pain
from a collapsed femoral head. Although the exact mechanism
underlying this disease is unknown, steroid use, alcohol abuse,
smoking, and sickle cell disease have been identified as associated
risk factors [1]. Effective nonsurgical treatment does not exist, and
the current standard surgical treatment includes joint arthroplasty,
bone grafting, and osteotomies [1].
Recently, many favorable clinical outcomes of cell-based therapy
have been reported [2e10]. Autologous concentrated bone marrow
Abbreviations: ONFH, osteonecrosis of the femoral head; ADL, activity of daily
living; JICHW, Japanese Investigation Committee of Health and Welfare; AE, adverse
event; VAS, visual analog scale; WOMAC, Western Ontario and McMaster Univer-
sities Osteoarthritis Index; JHEQ, Japanese Orthopaedic Association Hip Disease
Evaluation Questionnaire.
*Corresponding author. Department of Orthopaedics, Faculty of Medicine, Jun-
tendo University, 2-1-1, Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan.
E-mail address: yhomma@juntendo.ac.jp (Y. Homma).
Peer review under responsibility of the Japanese Society for Regenerative
Medicine.
Contents lists available at ScienceDirect
Regenerative Therapy
journal homepage: http://www.elsevier.com/locate/reth
https://doi.org/10.1016/j.reth.2022.03.002
2352-3204/©2022, The Japanese Society for Regenerative Medicine. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
Regenerative Therapy 20 (2022) 18e25
grafting is a major field in cell-based therapy that was first reported
by Hernigou P et al. [11]. The consensus is that this procedure is
more favorable before the collapse of the femoral head [12]. In the
review by Chughtai M et al., the femoral preservation rate using
cell-based therapy with bone marrow cells ranges between 53%
and 100% after 24e60 months [12]. Besides, as the safety of
autologous bone marrow, Hernigou P et al. reported the absence of
tumor development at the site of injection and no increased cancer
occurrence in 1873 patients with an average follow-up period of
12.5 years [13].
Moreover, in addition to the establishment of this procedure,
other associated related medical devices, the “point-of-care de-
vice,”for this specific procedure has been recently developed and is
currently available. These point-of-care devices include a bag for
the aspirated bone marrow, a centrifugation system, and a specific
trocar for injection. The bag is presterilized and partially closed,
which enables easy and concealed from external circumstance for
the concentrated bone marrow. The centrifugation systems of these
devices are cheap and compact, making them easy to carry. The
specific trocar is designed to accommodate the size of the femoral
head.
Although public healthcare systems and authorization processes
for medical procedures and devices vary among countries, more
patients with public insurance coverage are expected to undergo
better procedures. In Japan, autologous concentrated bone marrow
grafting is not yet authorized medical procedure, even though the
guidelines recommend this new procedure at level 2 (it is weakly
recommended or proposed)[1]. For a medical procedure to be
authorized with public health assurance coverage, robust evidence
of the safety and efficiency of this procedure and the point-of-care
devices is required. However, the evidence about BioCUE
R
(Zimmer
Biomet, IN, USA), a point-of-care device is scares [14e17 ]. More-
over, no study has confirmed the feasibility and safety of this pro-
cedure with this specific point-of-care devices in Japan. Therefore,
this study was conducted to investigate the feasibility and safety of
concentrated bone marrow grafting using BioCUE
R
(Zimmer Bio-
met, IN, USA), a point-of-care device.
2. Materials and methods
2.1. Ethics
The study protocol was approved by the Certified Committee for
Regenerative Medicine of Tokyo Medical and Dental University
(certification number: NA8140003) and submitted to the Ministry
of Health, Labour and Welfare. Written informed consent was ob-
tained from each participant, and the study was conducted ac-
cording to the Act on the Safety of Regenerative Medicine and the
tenets of the Declaration of Helsinki. The study was registered with
the Japan Registry of Clinical Trials (jRCTc032200027).
2.2. Study objectives and design
We designed this phase I, prospective, open-label clinical study
to evaluate the feasibility and safety of autologous concentrated
bone marrow grafting processed using a point-of-care device in
patients with ONFH.
2.3. Medical device used in this study
We used the BioCUE system (Zimmer Biomet, IN, USA) as the
point-of-care device in this study. This system comprised a single-
use tube (standard kit, 60 mL) for bone marrow aspiration and a
single-use 5.5-mm trocar for concentrated bone marrow injection.
2.4. Patients and eligibility criteria
Patients aged 20 years and diagnosed with ONFH were
recruited. The diagnostic criteria established by the Japanese
Investigation Committee of Health and Welfare (JICHW) was used
[18]. The stage and type of ONFH were classified according to the
classification system developed by the JICHW [18]. The inclusion
and exclusion criteria are presented in Table 1.
2.5. Bone marrow harvesting and concentration process
Under general anesthesia in the operating room, the patient was
placed in the supine position. The standard preventive protocol at
our hospital for surgical site infection, including administration of
prophylactic antibiotics (3.0 g sulbactameampicillin), was
employed preoperatively. After standard skin disinfection using
povidoneeiodine, an iodine-impregnated incision drape was
applied to the iliac crest and lateral aspect of the proximal femur.
Bone marrow aspiration was performed according to a previously
described method [11,19]. A 5-mm incision at approximately
20 mm posterior to the anterior superior iliac spine was made in
both iliacus wing to avoid the lateral femoral cutaneous nerve. A
bone marrow aspiration needle (8 G) was inserted into the bilateral
iliac spine, and a 20-mL syringe flushed with heparin sodium and
containing 2 mL heparin sodium was used to aspirate the bone
marrow. The tip of the needle was placed at different points mul-
tiple times. The aspirated bone marrow was packed into the ster-
ilized BioCUE standard kit (60 mL) according to the manufacturer's
instructions. Five kits for bilateral ONFH and three kits for unilateral
ONFH were prepared (one kit per patient for cell safety assessment
was prepared). The aspirated bone marrow was sent to the cell
processing unit of our hospital. According to the manufacturer's
instructions, centrifugation (3200 rpm for 15 min) was performed
to concentrate the bone marrow. After centrifugation, the plasma
and red-blood cell layer were removed, and the rest of the bone
marrow was stored in a 20-mL syringe and sent back to the oper-
ating room for injection.
2.6. Surgical technique
A skin incision of approximately 10 mm was made at the
proximal lateral aspect of the thigh on the femoral axis. The fascia
and muscle were minimally incised until the tip of the trocar was
placed on the femur. Using fluoroscopy, the tip of the trocar was
placed at the center of the osteonecrotic area in the anteroposterior
and mediolateral views (Fig. 1). Approximately 12 mL of concen-
trated bone marrow per femoral head was injected through the
trocar.
2.7. Postoperative protocol
Full-weight-bearing was allowed after the operation. A stick or
walking frame was provided as per the patient's demands. Low-
molecular-weight heparin (enoxaparin sodium, 2000 IU twice per
day) was administered. The patients were discharged 2e3 days
postoperatively.
2.8. Endpoints
The primary outcomes of this study were the safety and adverse
event (AE) profile of the grafting of autologous concentrated bone
marrow that was processed using a point-of-care device. AEs were
defined as any sign of the patients’condition worsening after
treatment, and they were classified according to the Common
Terminology Criteria for Adverse Events, version 4.0 (translated to
Y. Homma, Y. Masubuchi, Y. Shirogane et al. Regenerative Therapy 20 (2022) 18e25
19
Japanese by the Japan Clinical Oncology Group) [13] as serious (
grade 3) or nonserious (grade 2). In addition, AEs that met the
criteria set by the Act on the Safety of Regenerative Medicine, such
as hospitalization, were classified as serious; such cases were re-
ported and assessed by the Certified Committee for Regenerative
Medicine of Tokyo Medical and Dental University (certification
number: NA8140003) and submitted to the Ministry of Health,
Labour and Welfare.
Secondary outcomes included pain score using a visual analog
scale (VAS); hip function using scoring systems, such as Western
Ontario and McMaster Universities (WOMAC) Osteoarthritis Index
and Japanese Orthopaedic Association Hip Disease Evaluation
Questionnaire (JHEQ) [20]; ONFH stage using X-ray; and the volume
of the osteonecrotic area on 3T MRI using three-dimensional image
analysis system (SYNAPSE VINCENT, Fujifilm). The coronal plane on
T1-weighted imaging was used to evaluate the necrotic volume.
Necrotic area in this study was defined as the area on the inner side
of the black band (Fig. 2A). To calculate the necrotic area volume,
first, the entire femoral head was set as the region of interest
(Fig. 2B). Second, the area with an intensity level similar to that of the
black band was semi-automatically marked in every slice (Fig. 2C).
This allowed for the identification of areas other than the necrotic
area in every slice. Third, the intensity level was automatically
inverted, thus allowing the identification of necrotic areas in the
inner side of the black band in every slice, and the necrotic volume
was automatically calculated (Fig. 2D). The measurement of necrotic
volume was performed twice and expressed as a mean.
2.9. Safety evaluation for concentrated bone marrow
Safety quality tests on the final product of concentrated bone
marrow were performed as follows. Of note, sterility tests, negative
tests for mycoplasma, and bacterial endotoxin tests were out-
sourced (SRL, Tokyo, Japan).
- A visual inspection of concentrated bone marrow to detect
visible abnormalities.
- Rapid bacterial endotoxin test before grafting: the final concen-
trated bone marrow product and its diluted solution by 500
times were analyzed using Endosafe (Charles River, MA, USA).
- A sterility test of the final product performed using the direct
inoculation method with blood agar plate, GAM semisolid me-
dium, and trypticase soy agar for 48 h (in case of negative, the
test was extended to 78 h).
- Negative test for mycoplasma by testing the final product for
mycoplasma using the loop-mediated isothermal amplification
method.
- Bacterial endotoxin test: the kinetic turbidimetric test for
detecting endotoxins.
Table 1
Inclusion and exclusion criteria.
Patients: Idiopathic osteonecrosis of the femoral head.
Inclusion criteria Exclusion criteria
1. Idiopathic
osteonecrosis
of femoral head;
stages 1, 2,
and 3A
1. Patients with abnormal platelet counts
in peripheral blood
2. Age >20 years 2. Patient who smokes a lot
(Brinkman index >600)
3. Treatment with anticoagulants
4. Uncontrolled diabetes mellitus:
HbA1c not >9.0%
according to latest laboratory
data obtained within
14 days before registration
5. Patients with malignancy
6. Patients <6 months after onset of cardiac
infarction or cerebral infarction
7. Predictive survival period <1 year
8. Active infectious diseases
(e.g., HBV, HCV, HIV, and syphilis)
9. Dialysis patients
10. Age <20 years
11. Patients with dementia or coma
12. Previous surgical history for proximal femur
13. Anesthetist has determined that it is not
suitable for general anesthesia
14. Surgeon has determined that it is not
suitable for this clinical study
HbA1c: hemoglobin A1c, HBV: hepatitis B virus, HCV: hepatitis C virus, HIV: hepa-
titis I virus
Fig. 1. Trocar placed on the femur using a fluoroscope (A). The tip of the trocar is placed at the center of the osteonecrosis area in the anteroposterior and mediolateral views (B/C).
Y. Homma, Y. Masubuchi, Y. Shirogane et al. Regenerative Therapy 20 (2022) 18e25
20
2.10. Study period
The study was conducted at a single institution for >9 months,
with the patients enrolled and treated between April 1, 2020 and
June 30, 2020, and with the follow-up period ending on December
31, 2020.
3. Results
3.1. Patient demographics
Two patients (a 34-year-old man and a 33-year-old woman;
three hips) were included in this study (Table 2 ). Both patients had
systemic lupus erythematosus (SLE), had previously undergone
high-dose corticosteroid therapy (Case 1: intra-venous methyl-
prednisolone 1000 mg/day for three days, then oral prednisolone
60 mg/day, Case 2: oral prednisolone 30 mg), and were currently
undergoing oral corticosteroid drug therapy (Case 1: Oral pred-
nisolone 9mg/day, Case 2: Oral prednisolone 6.5 mg/day). Dura-
tion of steroid therapy was 22 months in Case 1 and 8 years in Case
2. According to the classification system developed by the JICHW
[10], patient 1 had unilateral ONFH with stage 2/type C1, whereas
patient 2 had bilateral ONFH with stage 3A/type C2 (right) and
stage 2/type C1. Both patients had hip pain one year before the
operation.
3.2. Primary endpoints
The incidence of AEs was 100% (Table 3), but all AEs were
nonserious. No intraoperative complications, such as iatrogenic
femoral fracture and intra-articular penetration of the trocar,
were observed. Immediate postoperative transient pain at the
incision site was noted for both patients. No postoperative com-
plications, such as hematoma and surgical site infection associ-
ated with the surgical technique, were observed. During the
observational period, no signs of infection or complications
associated with autologous concentrated bone marrow grafting
were observed.
3.3. Secondary endpoints
Pain VAS, JHEQ, and WOMAC scores remained unchanged from
the preoperative to the postoperative observational periods (Fig. 3).
According to the JICHW classification, all hips maintained the
Fig. 2. Necrotic area (white triangle) that is defined as the area on the inner side of the black band in this study (A). The entire femoral head is set as the region of interest (B).
Second, the area with an intensity level similar to that of the black band was semi-automatically marked in every slice (C). Third, the intensity level was automatically inverted (D).
Table 2
Patients’background.
S Age/Sex Hips Stage Type Related factors Height (cm) Weight (Kg) BMI
1 33/Male Right 2 C1 Steroid use (SLE) 167.1 64.3 23.1
2 34/Female Right 3A C2 Steroid use (SLE) 156.0 38.3 15.8
Left 2 C1
SLE: systematic lupus erythematosus, BMI: body mass index
Y. Homma, Y. Masubuchi, Y. Shirogane et al. Regenerative Therapy 20 (2022) 18e25
21
preoperative stage till the end of the observational periods (Fig. 4).
Preoperatively, the necrosis volume was 4.386. mL for patient 1 and
9.054 mL (right) and 4.8961 mL (left) for patient 2, whereas,
postoperatively, the necrosis volume was 4.188 mL for patient 1 and
1.804 mL (right) and 3. 636 mL (left) for patient 2 (Figs. 5 and 6). To
note, stage of right hip in patient 1 was progressed after the surgery
(Stage 3A to 3B), thereby the assessment of necrotic volume was
difficult assessed correctly.
3.4. Safety evaluation of the concentrated bone marrow
Visual inspection revealed that the concentrated bone marrow
was intact in all cases. A rapid bacterial endotoxin test before
grafting was performed for the final concentrated bone marrow
product and its 500 diluted solution, but the results were un-
measurable. After the grafting, the sterility test of the final product
was negative. Moreover, an extremely small amount of endotoxin
(0.05 EU/mL; 0.6 EU/one graft) was detected in patient 1.
4. Discussion
ONFH with a collapsed femoral head causes serious pain and af-
fects ADL; therefore, the prevention of disease progressionis desired.
Along with the accumulating evidence on the efficacy and safety of
autologous concentrated bone marrow injection before the collapse
stage of ONFH, the related medical device, the “point-of-care device”
has also been recentlydeveloped and is currently available. However,
no study has confirmed the feasibility, safety, and efficiency of
concentrated autologous bone marrow grafting using a specific
point-of-care device. In this study, no perioperative complications
were reported when using the point-of-care device BioCUE (Zimmer
Biomet, IN, USA) for autologous bone marrow grafting.
Table 3
Adverse events.
Case Adverse events Detail Degree of seriousness Outcome
１Pain Transient pain at the skin incision area, the iliac and thigh (NRS ¼2). Nonserious Recovered
Pain Transient pain at the lateral aspect of the thigh (NRS ¼2). Nonserious Recovered
Numbness Transient numbness at the lateral aspect of the thigh Nonserious Recovered
Fever Transient fever up, 37.0
C at POD-1, 37.1
C at POD-3 Nonserious Recovered
Rubefaction Transient skin redness at the dressing tape Nonserious Recovered
WBC elevated WBC count just after the operation: 10.3 x 10
3
/
m
L Nonserious Recovered
2 Pain Transient pain at the skin incision area, the iliac and thigh (NRS ¼2) Nonserious Recovered
Pain Transient pain at the lateral aspect of the thigh (NRS ¼2) Nonserious Recovered
Fever Transient fever up, 37.7
C at POD-1 Nonserious Recovered
Anemia Just after the operation, Hb 9.7g/dL, POD-1 9.3g/dL (Preoperatively: 12.4 g/dL) Nonserious Recovered
NRS, numerical rating scale (0: minimum pain, 10: maximum pain); POD, postoperative day; WBC, white blood cell
Fig. 3. Results of patient-reported outcomes using JHEQ and WOMAC demonstrated no deterioration after the procedure. Because Case 2 had bilateral procedures, the results were
shown both right and left side in JHEQ-Total, JHEQ-Pain, and JHEQ-Move score, totally three lines. Whereas other scores including JHEQ-Mental and WOMAC could notbe separated,
thereby there were two lines.
Y. Homma, Y. Masubuchi, Y. Shirogane et al. Regenerative Therapy 20 (2022) 18e25
22
For this medical procedure to be authorized with public health
assurance coverage, this technique with a point-of-care device
must be tested in a phase 2 or higher clinical trial or study. In this
study, no surgical complications, such as intraoperative fracture or
surgical site infection, were observed. Additionally, although the
observation period was relatively short, the patient-reported out-
comes using JHEQ and WOMAC indicated that the preoperative
status was maintained immediately after the operation and at 6
months postoperatively; this suggests that this technique is mini-
mally invasive and does not require any postoperative restrictions.
As patients with ONFH are generally young, returning to work and
usual ADL are beneficial after the operation. Moreover, in terms of
safety, the sterility and mycoplasma virus tests reported negative
results, and the bacterial endotoxin level was under the threshold.
This safety confirmation for a final cell product is essential to pro-
ceed with further studies and will enable it to be an authorized
medical procedure with public health assurance coverage.
Although previous reports and our results demonstrated safety
and efficiencyin this procedure, there areseveral discussionpoints to
note. First, the indication of this procedure should be clear in the
future. In general, a volume of necrotic area and status of disease
progression are considered. Concerning about the volume, aswe did
not set the volume of osteonecrosis (So called Type in JICHW classi-
fication) as. an inclusion and exclusion criteria, we believe that this
procedure should not be limited depending on the volume. In
contrast, the status of disease progression (So called Stage in JICHW
Fig. 4. Result of disease staging using X-ray. No stage progression is observed. A: Preoperative image of patient 1. B: Postoperative image of patient 1. C: Preoperative image of
patient 2 (right hip). D: Postoperative image of patient 2 (right hip). E: Preoperative image of patient 2 (left hip). F: Postoperative image of patient 2 (left hip).
Y. Homma, Y. Masubuchi, Y. Shirogane et al. Regenerative Therapy 20 (2022) 18e25
23
classification) must be consideredfor the indication of this procedure.
There is no doubt the pre-collapse stage is the best timing of this
procedure [12]. Whereas, although the collapsed stage with osteo-
arthritis change is not candidate, the outcome for collapsed stage
without osteoarthritis change should be investigated in the future.
Second, the optimal location of trocar should be discussed, particu-
larly in massive osteonecrosis case such as Type C in JICHW classifi-
cation. In this study, since the volume was not large, the trocar must
be placed at the center of necrotic area. However, in large necrotic
volume case, it is still unclear that the tip of trocar should be placedat
the center of the femoral head for equal distribution of the concen-
trated bonemarrow in the necroticarea or placed at the lateral areaof
the femoral head for focalization of the concentrated bone marrow at
most mechanical loading area. Third, ideal post-operative rehabili-
tation protocol should be investigated in the future. Although full
weight bearing was allowed in our cases, the protocol modification
may influence on the outcome in case of massive osteonecrosis or
collapsed case. Fourth, the comparison bilateral surgery to two sur-
geries for bilateral ONFH should be debated. In our case 2, bilateral
surgery was selected because this procedure is minimum invasive
allowing full-weight bearing after the operation. In case of two sur-
geries, the risk of disease progression at non-operative side and
doubled risk of anesthesia might compromise the benefitofthis
minimum invasive procedure.
Point-of-care devices are considered useful tools. The bag for
aspirated bone marrow is easy to use and is partially closed, which
prevents contamination during bone marrow manipulation. The
centrifugation system is also cheap and compact, which enables a
larger number of users and makes setting up the cell-processing area
easier. These meritsare not seen in the centrifugation systems used in
previous studies, one of which included a high-quality, large, and
expensive centrifugation system with various modes and conditions
for leukemiaand other diseases. Moreover, excellent cell outputusing
the deviceused in this study has been reported[21]. Wodell-Mayet al.
have used the same device and showed a higher recovery rate of
mononuclearcells than when using the Ficoll gradient centrifugation
method [21]. So far,the clinical efficiency of BioCUE
R
(the same device
with different product name, Marrow Stim: Biomet Biologics) for not
only ONFH [17] but also other disease has been reported [14e16],
even though the number of those articles are limited.
The development of a rapid testing method for the cell quality of
concentrated bone marrow as the final product is necessary.
Although cell quality tests, such as sterility, mycoplasma virus, and
bacterial endotoxin tests, would be performed as a general princi-
ple in the cell-based therapy, those results take several days. In
contrast to cell-based therapy using cell culture, where testing
before the administration of the final product is possible, it was
possible to inject concentrated bone marrow within approximately
45 min after harvesting from the iliac crest. Thereby, rapid testing is
useful to detect bacterial and viral contamination before adminis-
tration, even though the possibility of contamination is minimal. In
this study, Endosafe (Charles River, MA, USA), a rapid bacterial
endotoxin testing system, was used to examine the final concen-
trated bone marrow. However, although the standard analysis
process was followed, the results turned were unmeasurable
because of the high density of the cells. Generally, a rapid endotoxin
test using a specific device such as Endosafe (Charles River, MA,
USA) is performed for cell-free products, such as plasma or super-
natant of cell culture. Further investigation is necessary to establish
an evaluation method to examine the cell quality in cell-based
therapy using noncultured autologous rapid administration after
Fig. 5. Change in necrotic volume on magnetic resonance imaging. AeC: Preoperative image of patient 1. BeF: Postoperative image of patient 1. GeK: Preoperative image of patient
2 (right hip). HeI: Postoperative image of patient 2 (right hip). MeQ: Preoperative image of patient 2 (left hip). NeR: Postoperative of patient 2 (left hip).
Fig. 6. The change of necrotic volume af ter the procedure. Blue line indicates right hip
in patient 1, red line indicates left hip in patients 1. Right hip in patient 1 was not
demonstrated in this figure, since due to stage progression after the surgery (Stage 3A
to 3B), the assessment of necrotic volume was not assessed correctly.
Y. Homma, Y. Masubuchi, Y. Shirogane et al. Regenerative Therapy 20 (2022) 18e25
24
harvesting, such as platelet-rich plasma injection or concentrated
bone marrow grafting.
We acknowledge several limitations to this study. First, the
number of patients who underwent the procedure in this study was
only two with three hips. However, the important feature of this
study is that it presents the feasibility and safety of this procedure
using a point-of-care device. This study serves as the first step in
confirming the safety and efficiency of this procedure using a point-
of-care device in the clinical study including a large number of pa-
tients, leading to its approval with public health assurance coverage.
Second, the two patients included in this study had the same co-
morbidity, that is, SLE; thereby, the feasibility and safety of this pro-
cedure for patients with other comorbidities remain unknown.
Although we think that the feasibility and safety of this procedure for
patients with other comorbiditiesare not inferior to the results of this
study, a further study involving a large number of patients with
various comorbidities should be conducted. Third, although the
safety quality of the final product after centrifugation had been vali-
dated, the quality of cell output in terms of efficiency, such as the
number of cells after centrifugation, using this point-of-care device
was not analyzed in this study. However, previous studies using the
same point-of-care device demonstrated excellent cell output, such
as a high recovery rate of mononuclear cells [21]. The relationship
between cell output and clinical consequences should be analyzed in
the future. Fourth, although we used the three-dimensional image
analysis system (SYNAPSE VINCENT, Fujifilm) in this study, the reli-
ability and validity of this method for osteonecrotic volume have not
yet been validated. Particularly, calculating the volume of the black
area within the black band was difficult; for example, the right hip of
patient 2 in this study, especially after the grafting. However, this
study was conducted to confirm the feasibility and safety of this
procedure; therefore, the validation for necrotic volume analysis
should be tested in other studies.
5. Conclusions
In this study, we confirmed the feasibility and safety of grafting
of concentrated autologous bone marrow in patients with ONFH
using a point-of-care device. A further clinical study aiming for the
authorization of this procedure should be conducted in the future.
Declaration of competing interest
There are potential competing interests. Yasuhiro Homma and
Tomonori Baba had honoraria for lectures about hip arthroplasty
from Zimmer Biomet Japan. Tomonori Baba and Muneaki Ishijima
had a scholarship grant from Zimmer Biomet Japan, which was not
used for this study. Kazuo Kaneko and Muneaki Ishijima were
representatives for endowed department from several industries
including Zimmer Biomet (Kaneko Kazuo: 2019, 2020 and 2021
until March, Muneaki Ishijima: from April 2021). Kazuo Kaneko and
Muneaki Ishijima were not involved in data management, moni-
toring, and statistical analysis. Tomonori Baba was a member (non-
paid) of endowed department from several industries including
Zimmer Biomet since September 2021.
Acknowledgments
This research was supported by Juntendo University Capture of
Outstanding Clinical Research and Evolution (CORE) project.
References
[1] Ando W, Sakai T, Fukushima W, Kaneuji A, Ueshima K, Yamasaki T, et al.
Japanese Orthopaedic Association 2019 Guidelines for osteonecrosis of the
femoral head. J Orthop Sci 2021;26(1):46e68.
[2] Tomaru Y, Yoshioka T, Sugaya H, Shimizu Y, Aoto K, Wada H, et al. Mid-term
results of concentrated autologous bone marrow aspirate transplantation for
corticosteroid-associated osteonecrosis of the femoral head in systemic lupus
erythematosus. Int Orthop 2018;42(7):1623e30.
[3] Tomaru Y, Yoshioka T, Sugaya H, Kumagai H, Hyodo K, Aoto K, et al. Ten-year
results of concentrated autologous bone marrow aspirate transplantation for
osteonecrosis of the femoral head: a retrospective study. BMC Muscoskel
Disord 2019;20(1):410.
[4] Yamasaki T, Yasunaga Y, Ishikawa M, Hamaki T, Ochi M. Bone-marrow-
derived mononuclear cells with a porous hydroxyapatite scaffold for the
treatment of osteonecrosis of the femoral head: a preliminary study. J Bone
Joint Surg Br 2010;92(3):337e41.
[5] Zhao D, Cui D, Wang B, Tian F, Guo L, Yang L, et al. Treatment of early stage
osteonecrosis of the femoral head with autologous implantation of bone
marrow-derived and cultured mesenchymal stem cells. Bone 2012;50(1):
325e30.
[6] Gangji V, De Maertelaer V, Hauzeur JP. Autologous bone marrow cell im-
plantation in the treatment of non-traumatic osteonecrosis of the femoral
head: five year follow-up of a prospective controlled study. Bone 2011;49(5):
1005e9.
[7] Ma Y, Wang T, Liao J, Gu H, Lin X, Jiang Q, et al. Efficacy of autologous bone
marrow buffy coat grafting combined with core decompression in patients
with avascular necrosis of femoral head: a prospective, double-blinded, ran-
domized, controlled study. Stem Cell Res Ther 2014;5(5):115.
[8] Tabatabaee RM, Saberi S, Parvizi J, Mortazavi SM, Farzan M. Combining
concentrated autologous bone marrow stem cells injection with core
decompression improves outcome for patients with early-stage osteonecrosis
of the femoral head: a comparative study. J Arthroplasty 2015;30(9 Suppl):
11e5.
[9] Mao Q, Jin H, Liao F, Xiao L, Chen D, Tong P. The efficacy of targeted intra-
arterial delivery of concentrated autologous bone marrow containing mono-
nuclear cells in the treatment of osteonecrosis of the femoral head: a five year
follow-up study. Bone 2013;57(2):509e16.
[10] Pepke W, Kasten P, Beckmann NA, Janicki P, Egermann M. Core decompres-
sion and autologous bone marrow concentrate for treatment of femoral head
osteonecrosis: a randomized prospective study. Orthop Rev 2016;8(1):6162.
[11] Hernigou P, Beaujean F. Treatment of osteonecrosis with autologous bone
marrow grafting. Clin Orthop Relat Res 2002;405:14e23.
[12] Chughtai M, Piuzzi NS, Khlopas A, Jones LC, Goodman SB, Mont MA. An
evidence-based guide to the treatment of osteonecrosis of the femoral head.
Bone Joint J 2017;99-b(10):1267e79.
[13] Hernigou P, Homma Y, Flouzat-Lachaniette CH, Poignard A, Chevallier N,
Rouard H. Cancer risk is not increased in patients treated for orthopaedic
diseases with autologous bone marrow cell concentrate. J Bone Joint Surg Am
2013;95(24):2215e21.
[14] Torres J, Gutierres M, Lopes MA, Santos JD, Cabral AT, Pinto R, et al. Bone
marrow stem cells added to a hydroxyapatite scaffold result in better out-
comes after surgical treatment of intertrochanteric hip fractures. BioMed Res
Int 2014;2014:451781.
[15] Liang TW, Jester A, Motaganahalli RL, Wilson MG, G'Sell P, Akingba GA, et al.
Autologous bone marrow mononuclear cell therapy for critical limb ischemia
is effective and durable. J Vasc Surg 2016;63(6):1541e5.
[16] Hede K, Christensen BB, Jensen J, Foldager CB, Lind M. Combined bone marrow
aspirate and platelet-rich plasma for cartilage repair: two-year clinical results.
Cartilage 2021;13(1_suppl):937s. 47s.
[17] Aarvold A, Smith JO, Tayton ER, Jones AM, Dawson JI, Lanham S, et al. A tissue
engineering strategy for the treatment of avascular necrosis of the femoral
head. Surgeon 2013;11(6):319e25.
[18] Sugano N, Atsumi T, Ohzono K, Kubo T, Hotokebuchi T, Takaoka K. The 2001
revised criteria for diagnosis, classification, and staging of idiopathic osteo-
necrosis of the femoral head. J Orthop Sci 2002;7(5):601e5.
[19] Hernigou J, Picard L, Alves A, Silvera J, Homma Y, Hernigou P. Understanding
bone safety zones during bone marrow aspiration from the iliac crest: the
sector rule. Int Orthop 2014;38(11):2377e84.
[20] Matsumoto T, Kaneuji A, Hiejima Y, Sugiyama H, Akiyama H, Atsumi T, et al.
Japanese orthopaedic association hip disease evaluation Questionnaire
(JHEQ): a patient-based evaluation tool for hip-joint disease. The subcom-
mittee on hip disease evaluation of the clinical outcome committee of the
Japanese orthopaedic association. J Orthop Sci 2012;17(1):25e38.
[21] Woodell-May JE, Tan ML, King WJ, Swift MJ, Welch ZR, Murphy MP, et al.
Characterization of the cellular output of a point-of-care device and the im-
plications for addressing critical limb ischemia. Biores Open Access 2015;4(1):
417e24.
Y. Homma, Y. Masubuchi, Y. Shirogane et al. Regenerative Therapy 20 (2022) 18e25
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